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My research focuses on studying phenomenology, vulnerability factors, and psychiatric and medical comorbidity of panic disorder in old age, as well as treatment responses to medication in elders with panic disorder. I am presently involved in establishing and extending our preliminary finding that Late-Onset Panic Disorder (LOPD) (onset at or after age 55) is a phenomenologically distinct syndrome from Early-Onset Panic Disorder (EOPD). This is being accomplished by comparing LOPD subjects with EOPD subjects on multiple standardized measures assessing the domains of phenomenology, vulnerability factors, and psychiatric and medical comorbidity. Additionally, our group has recently completed pilot studies of both pharmacological and nonpharmacological treatment strategies of panic disorder in old age. Presently, we are planning a large-scale study comparing the efficacy of pharmacological and nonpharmacological treatments of panic disorder in older adults. Finally, a pilot project to investigate the phenomenology and treatment of anxiety in older Asian-Americans is underway.

Abstract

Scheduled exposure to bright light (phototherapy) has been used, with varying degrees of success, to treat sleep disruption in older individuals. Most of these studies have been done in institutional settings and have used several hours of daily light exposure. Such a regimen in the home setting may be untenable, especially when the individual with the sleep disruption has memory impairment and is being cared for by a family member. As such, we examined the effectiveness of a "user-friendly" phototherapy protocol that would be readily usable in the home environment.We exposed a group of 54 older caregiver/care recipient dyads, in which the care recipient had memory impairment, to two weeks of morning bright light phototherapy. Dyads were exposed to either bright white (∼4200 lux) or dim red (∼90 lux) light for 30 min every day, starting within 30 min of rising. All subjects also received sleep hygiene therapy. Objective (actigraphy) and subjective measures of sleep and mood were obtained at baseline and at the end of the two weeks of phototherapy.In care recipients, actigraphy- and log-determined time in bed and total sleep time declined in the active condition (p<0.05, ANOVA); there was no corresponding change in subjective insomnia symptoms (p's>0.37, ANOVA). The decrease in the time in bed was associated with an earlier out of bed time in the morning (p<0.001, Pearson correlation). The decrease in the total sleep time was associated with a decrease in sleep efficiency (p<0.001, Pearson correlation) and an increase in wake after sleep onset (p<0.001, Pearson correlation). In caregivers, there were no differential changes in actigraphic measures of sleep (p's>0.05, ANOVA). Actigraphy-measured wake after sleep onset and sleep efficiency did, however, improve in both conditions, as did sleepiness, insomnia symptoms, and depressive symptomatology (p's<0.05, ANOVA).Exposure to this regimen of phototherapy diminished sleep in older individuals with memory impairments. Their caregivers, however, experienced an improvement in sleep and mood that appeared independent of the phototherapy and likely due to participation in this protocol or the sleep hygiene therapy.

Abstract

To determine if results from randomized clinical trials of donepezil in Alzheimer disease (AD) patients can be applied to AD patients in clinical practice by comparing the findings from a Nordic one-year randomized AD donepezil trial with data from a one-year prospective, observational study of AD patients.AD patients from a consortium of California sites were systematically followed for at least one year. Their treatment regimens, including prescription of donepezil, were determined by their individual physician according to his or her usual criteria.The 148 California patients treated with donepezil had a one-year decline of 1.3 (3.5 SD) points on the Mini-Mental State Exam compared to a decline of 3.3 (4.4 SD) in the 158 AD patients who received no anti-Alzheimer drugs. The Mini-Mental State Exam decline in Nordic sample was approximately 0.25 points for the 91 patients receiving donepezil and approximately 2.2 for the 98 placebo patients. The overall effect sizes were estimated at about 0.49 in both studies. The California data were further analyzed using propensity methods; after taking into account differences that could bias prescribing decisions, benefits associated with taking donepezil remained.A comparison of a randomized clinical trial of donepezil in AD patients and this observational study indicates that if appropriate methodological and statistical precautions are undertaken, then results from randomized clinical trials can be predictive with AD patients in clinical practice. This California study supports the modest effectiveness of donepezil in AD patients having clinical characteristics similar to those of the Nordic study.

Abstract

This article describes a method for extracting heart rate (HR) and respiratory sinus arrhythmia (RSA) from the kinetocardiogram (KCG) recorded from accelerometers embedded in a mattress topper. Validation has been performed via comparison with simultaneously recorded ECG. All-night estimates of HR and RSA magnitude derived from both methods were highly correlated. KCG-derived estimates of HR were slightly lower, and those of RSA magnitude higher, than those derived from ECG. These biases are consistent with the need to constrain KCG estimation to periods free of body movement. Mattress actigraphy represents a zero-burden method of obtaining intensive longitudinal indices of cardiac status.

Abstract

Studies imposing rigorous control over lifetime alcohol intake have usually not found smaller hippocampal volumes in persons with posttraumatic stress disorder. Because the majority of negative studies have used adolescent samples, it has been suggested that chronicity is a necessary condition for such findings. To test the hypothesis that a smaller hippocampus in PTSD is unrelated to comorbid alcoholism or to chronicity, this study estimated hippocampal volume in a relatively large group (N=99) of combat veterans in which PTSD, lifetime alcohol abuse/dependence, and Vietnam versus Gulf War service were crossed. In subjects with histories of alcoholism, unadjusted hippocampal volume was 9% smaller in persons with PTSD than in those without PTSD. In nonalcoholic subjects, the PTSD-related difference in hippocampal volume was 3%. The failure to observe a strong association between PTSD and hippocampal volume in nonalcoholic subjects was not ascribable to younger age, reduced PTSD chronicity, or lower PTSD symptom severity. The possibility that smaller hippocampal volume is limited to groups in which PTSD is compounded by comorbid alcoholism is not necessarily incompatible with results suggesting a smaller hippocampus is predispositional to PTSD. Further examination of the role of alcoholism and other comorbid conditions in studies of brain structure and function in PTSD appears warranted.

Abstract

The current study used Department of Veteran's Affairs (VA) clinical records, State of California pesticide application records, spatial maps of distribution of Parkinson's disease patients, and pesticide applications to determine if there was evidence for "blow-in" of pesticides as a factor in explaining the prevalence of Central Valley Parkinson's disease. The results did not support the hypothesis of increasing prevalence of Parkinsonism attributable to wind drift.

Abstract

Off-label prescribing of medications, polypharmacy, and other questionable prescribing practices have led investigators to examine a large VA pharmacy database to determine if physician prescribing decisions appear reasonable.The current study addresses the question of physician prescribing of atypical antipsychotics in 34,925 veterans with schizophrenia, using a series of signal detection analyses.These results suggest that only three factors (hospital size, age, and secondary diagnosis) allow classification of patients prescribed atypicals into three groups with frequencies of use of atypicals ranging from 43% to 79%, and that these results are consistent with reasonable clinical practice.Results of two-stage signal detection analyses are readily interpretable by clinicians and administrators who are faced with the task of evaluating how physicians prescribe medications in clinical practice. Physicians' decisions to prescribe atypical antipsychotics are based on both patient and fiscal considerations. This likely reflects a combination of clinical judgment and institutional guidelines.

Abstract

This article reports preliminary data on trauma and post-traumatic stress disorder (PTSD) prevalence, as well as test psychometrics, among 35 cognitively intact veterans residing in long-term care settings. Participants received a traumatic event screening, the Mini-Mental Status Examination, Combat Exposure Scale (CES), PTSD Checklist (PCL), and Mississippi Combat PTSD Scale (M-PTSD). Results demonstrated adequate reliability for the CES, PCL, and M-PTSD for use in these settings, with several significant intercorrelations. A high prevalence of trauma exposure was found, in particular combat. Based on the PCL and M-PTSD, although most veterans did not meet full PTSD diagnostic criteria, a moderate proportion met partial criteria. The need for assessment and treatment of trauma exposure and PTSD in Veterans Affairs long-term care settings is emphasized.

Abstract

This descriptive study examined reports of behavioral problems among older patients hospitalized in acute care medical settings. Greater numbers of behavioral problems were reported by nursing staff on the Neuropsychiatric Inventory-Questionnaire than were documented in medical charts over the same time period. Such underreporting may have clinical and administrative implications.

Abstract

Both sleep disturbances and anxiety are quite common in older adults. Although increasing research efforts have investigated sleep disturbances and anxiety in older adults, little has been written concerning the relation between sleep disturbances and anxiety in this population. This article reviews the epidemiological and clinical literature concerning the overall prevalence of sleep disturbances and relations between sleep and anxiety in later life. The article begins with a discussion of the prevalence of sleep and anxiety problems in older individuals, continues with a clinical review of the complex interrelationship between sleep and anxiety in older adults, and briefly considers possible neurobiological underpinnings of this interrelationship. This is followed by a brief discussion of the impact of medical illness on both anxiety and sleep disturbances. The article ends with a summary of findings from this review and provides recommendations for future research.

Abstract

The frequent comorbidity of anxiety and depression, particularly among elderly, is widely recognized by clinicians, but the debate continues as to whether the combined diagnostic designation is merited. This article reviews the debate over the mixed diagnosis, discusses treatment implications, and reviews a small treatment study undertaken with elderly patients. Ten community-dwelling, older adults diagnosed with generalized anxiety disorder and subsyndromal depression (n = 6) or generalized anxiety disorder and major depressive disorder (n = 4) were started on a 12-week, open-label trial of nefazodone. Clinicians' ratings on the Clinical Global Impression of Change and patients' self-ratings of symptoms on the Beck Depression Inventory and the Beck Anxiety Inventory identified statistically significant gains in patients' overall pre/post functioning. Nefazodone was efficacious in symptom alleviation in patients with comorbid anxiety and depression. Further double-blind, randomized investigations with newer antidepressant medications are required to extend these preliminary findings with nefazodone.

Abstract

There is paucity of medical literature on the use of lamotrigine in elderly patients who have behavior problems and diverse psychiatric syndromes. This article is a retrospective case series summarizing the authors' experience with this medication. In a 20-patient case series from an institutional review board-approved retrospective chart review, the tolerability and efficacy of lamotrigine was evaluated for the management of agitated and aggressive behaviors in nursing home patients with a range of psychiatric and medical diagnoses. Nineteen of the elderly nursing home patients tolerated lamotrigine treatment, and 18 showed modest clinical improvement. These results support the authors' belief that controlled clinical investigations of this medication should be performed.

Abstract

This study examined the association of posttraumatic stress disorder (PTSD) with the quality of intimate relationships among present-day male World War II ex-prisoners of war (POWs). Ex-POWs had considerable marital stability; those with PTSD were no less likely to be in an intimate relationship. Ex-POWs in an intimate relationship who had PTSD (N=125 ) were compared with ex-POWs in a relationship who did not have PTSD (N=206). Marital functioning was within a range expected for persons without traumatic exposure. Yet, over 30% of those with PTSD reported relationship problems compared with only 11% of those without PTSD. Ex-POWs with PTSD reported poorer adjustment and communication with their partners and more difficulties with intimacy. Emotional numbing was significantly associated with relationship difficulties independent of other symptom complexes and severity of PTSD. Implications for clinical practice are discussed.

Abstract

The purpose of this study was to assess whether pharmacy database information from US Department of Veterans Affairs (VA) medical centers could be used to screen for areas of higher Parkinson's disease prevalence in patients exposed to pesticides. The authors used pharmacy data sets and compared the use of antiparkinsonian medications at 2 VA medical centers in California: one in Palo Alto, near the ocean, and one in Fresno, downwind from extensively farmed parts of the Central Valley. They found that patients at Fresno had higher odds ratios (1.5-1.8) for the use of Parkinson's disease medications than patients at Palo Alto. These data are consistent with the observations of prior epidemiologic studies and suggest that VA pharmacy databases can prioritize locations for further epidemiologic research. However, a thorough exploration of alternative explanations is needed to reach definitive conclusions regarding the findings suggested by this method.

Abstract

The authors compared young and older adults with panic disorder (PD) to investigate differences in panic-associated phenomenology, psychiatric comorbidity, and risk factors.Patients in the older group (age 60 and above) were further subdivided into early- and late-onset groups and compared. Phenomenology (number of panic symptoms, severity of anxiety, physiological symptoms, panic-associated cognitions, and overall severity of PD); comorbidity (depressive and anxiety disorders); and risk factors (family history of anxiety and life stressors) were assessed in 167 outpatients with PD.Older patients reported fewer panic symptoms, less anxiety and arousal, less severe PD, lower levels of depression, and higher levels of functioning. Furthermore, within the older-patient group, late-onset patients were found to report less distress during panic attacks in relation to body sensations and panic-related cognitions and emotions. Multiple-regression analysis of the entire sample showed that chronological age and age at onset of PD distinctly predicted different domains of panic phenomenology.PD was consistently less severe in older patients across multiple domains, and a later age at onset was associated with less distress due to body sensations, cognitions, and emotions during panic attacks.

Abstract

To report on the efficacy, safety, and tolerability of sertraline in the treatment of elderly depres-sed patients with and without comorbid medical illness.Multicenter.Randomized, double-blind, placebo-controlled study.A total of 752 patients aged 60 and older with diagnosis of major depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis.Outcome measures included the 17-item Hamilton Depression Scale (HAMD); the Clinical Global Depression-Severity/Improvement (CGI-S/CGI-I); efficacy and safety/adverse event assessments; Quality of Life, Enjoyment, and Satisfaction Questionnaire; and the Medical Outcomes Study 36-Item Short-Form Health Status Survey.In the overall sample, sertraline was superior to placebo on all three primary outcome measures, HAMD, and overall clinical severity and change (CGI-S/CGI-I). Furthermore, therapeutic response to sertraline was comparable in those with or without medical comorbidity, and there were no treatment-by-comorbidity group interactions. Sertraline was also associated with a faster time to response than placebo in the comorbid group (P

Abstract

Although olanzapine has been widely adopted as a treatment of choice for schizophrenia, its long-term effectiveness and costs have not been evaluated in a controlled trial in comparison with a standard antipsychotic drug.To evaluate the effectiveness and cost impact of olanzapine compared with haloperidol in the treatment of schizophrenia.Double-blind, randomized controlled trial with randomization conducted between June 1998 and June 2000 at 17 US Department of Veterans Affairs medical centers.Three hundred nine patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of schizophrenia or schizoaffective disorder, serious symptoms, and serious dysfunction for the previous 2 years. Fifty-nine percent fully completed and 36% partially completed follow-up assessments.Patients were randomly assigned to receive flexibly dosed olanzapine, 5 to 20 mg/d, with prophylactic benztropine, 1 to 4 mg/d (n = 159); or haloperidol, 5 to 20 mg/d (n = 150), for 12 months.Standardized measures of symptoms, quality of life, neurocognitive status, and adverse effects of medication. Veterans Affairs administrative data and interviews concerning non-VA service use were used to estimate costs from the perspective of the VA health care system and society as a whole (ie, consumption of all resources on behalf of these patients).There were no significant differences between groups in study retention; positive, negative, or total symptoms of schizophrenia; quality of life; or extrapyramidal symptoms. Olanzapine was associated with reduced akathisia in the intention-to-treat analysis (P

Abstract

Recent epidemiologic surveys indicate that anxiety disorders in older adults are more common than previously believed. Despite this, knowledge regarding the clinical characteristics of anxiety disorders in elderly patients is emerging slowly. In addition, detection of anxiety symptoms in elders is complicated by several factors, including a confounding of symptom picture by high medical comorbidity, frequent use of multiple prescribed and over-the-counter medications, difficulty of differentiating anxiety from depression, and a tendency of some older adults to resist psychiatric evaluation. Nonetheless, a comprehensive evaluation that includes a clinical interview, self-report measures, and laboratory results, can improve detection and accurate assessment of anxiety in elderly patients. Empirically validated knowledge regarding appropriate pharmacologic interventions in elderly patients is still sparse, and inferences from data in young and middle-aged populations typically form the basis of clinical practice in elderly patients. SSRIs and SNRIs are considered first-line interventions because of their efficacy and relative tolerability in elderly patients. Psychotherapy, particularly cognitive-behavioral therapy, also has been found to be efficacious for older adults with anxiety disorders. Collaborative care models that address physician, patient, and healthcare service delivery barriers, also hold promise for adequately treating anxiety disorders experienced by older adults.

Abstract

We used a novel application of a signal detection technique, receiver operator characteristics (ROC), to describe factors entering a physician's decision to switch a patient from a typical high potency neuroleptic to a particular atypical, olanzapine (OLA) or risperidone (RIS).ROC analyses were performed on pharmacy records of 476 VA patients who had been treated on a high potency neuroleptic then changed to either OLA or RIS.Overall 68% patients switched to OLA and 32% to RIS. The best predictor of neuroleptic choice was age at switch, with 78% of patients aged less than 55 years receiving OLA and 51% of those aged greater than or equal to 55 years receiving OLA (chi(2)=38.2, P<0.001). Further analysis of the former group indicated that adding the predictor of one or more inpatient days to age increased the likelihood of an OLA switch from 78% to 85% (chi(2)=7.3, P<0.01) while further analysis of the latter group indicated that adding the predictor of less than 10 inpatients days to age decreased the likelihood of an OLA switch from 51% to 45% (chi(2)=7.0, P<0.01).ROC analyses have the advantage over other analyses, such as regression techniques, insofar as their "cut-points" are readily interpretable, their sequential use forms an intuitive "decision tree" and allows the potential identification of clinically relevant "subgroups". The software used in this analysis is in the public domain (http://mirecc.stanford.edu).

Abstract

This study examined whether symptoms of depression and concomitant anxiety differed between older and younger medical outpatients referred to a behavioral medicine clinic. In a sample of 178 male veterans aged 21-83 years, older adults (> or = 60 years) reported lower overall depressive symptoms on the Beck Depression Inventory (BDI) and anxiety symptoms on the State-Trait Anxiety Inventory than did younger adults ( < 60 years). Depressive symptoms were highly prevalent. Among older adults, 60.0% scored 10 or higher on BDI and 33.8% scored 16 or higher. Among younger adults, 70.8% scored 10 or higher on BDI, and 48.7% scored 16 or higher. The age difference in overall depressive symptoms was driven by cognitive-affective symptoms. While older adults had lower cognitive-affective symptoms than did younger adults, the two groups did not differ on somatic-performance symptoms. these results suggest the importance of assessing cognitive-affective depressive symptoms in both older and younger male medical outpatients.

Abstract

Disturbed sleep is a common clinical problem in anxiety disorders, particularly in patients with post-traumatic stress disorder (PTSD) and panic disorder (PD). Several studies have attempted to validate the subjective sleep complaints of these disorders using laboratory polysomnography. These attempts, typically focusing on PTSD or PD independently, have demonstrated inconsistent results. To our knowledge, no such studies have attempted to directly compare and contrast sleep disturbances in PTSD and PD together. Our review of the studies of subjective sleep disturbances, sleep architecture, and sleep-related biologic phenomena suggests that a comparative characterization of sleep disturbances in these two disorders is timely. Such an inference is based on our identification of several areas of convergence and divergence between PTSD and PD found in the published literature, as well as our own preliminary investigations. Specifically, PTSD and PD seem to converge on several sleep-related parameters, namely, sleep quality, presence of episodic parasomnias, and movement time. They also appear to diverge in other important sleep-related areas such as respiratory disturbances and the particular phenomenological nature of episodic parasomnias, namely nightmares or nocturnal panic attacks. Investigations focusing on such overlapping phenomena may provide groundwork for further elucidation of central fear systems underlying these two disorders. Additionally, such sleep studies have the potential to provide important insights into ongoing efforts to develop a cohesive conceptual framework into the patho-physiologies of these disorders.

Abstract

Prior research on patients with substance use disorders has shown that lifetime physical or sexual abuse is associated with more impaired functioning at treatment intake. The present study sought to determine whether physical or sexual abuse also predicted treatment response (posttreatment outcomes) of individuals with substance use disorders.Male (n = 19,989) and female (n = 622) veterans with substance use disorders were assessed with the Addiction Severity Index (ASI) early in treatment and reassessed an average of 12 months later. Treatment outcomes were compared for patients who did and did not report prior physical or sexual abuse in the initial ASI interview.Lifetime physical or sexual abuse predicted worse outcomes in six of seven domains of functioning, after controlling for baseline functioning, psychiatric diagnoses and demographic variables. Although women were more likely than men to report being abused, the effect of abuse on treatment outcomes was similar for both genders. Psychiatric problems at baseline mediated the effect of abuse history on outcomes. Abuse history moderated the effect of treatment intensity (contacts per month) on outcomes: More frequent treatment contacts were more beneficial for abused patients than for nonabused patients.Individuals with substance use disorders who have a history of physical or sexual abuse may have higher risk for problematic treatment outcomes as a result of greater psychiatric problems, deficits in social support and possible difficulties in establishing treatment alliance. Clinicians may consider increasing the duration and intensity of treatment to temper the negative effects of abuse on later functioning.

Abstract

Patients with post-traumatic stress disorder (PTSD) are frequently diagnosed with other psychiatric comorbid conditions. This study tested the hypothesis that PTSD patients suffer a greater proportion of sleep problems according to comorbid diagnoses.National Comorbidity Survey (NCS) data from 591 individuals diagnosed with PTSD were analyzed. Revised versions of the Diagnostic Interview Schedule and Composite International Diagnostic Interview were administered to a representative sample of males and females. Groups consisted of patients diagnosed with lifetime PTSD and with current comorbid panic disorder, major depressive disorder, generalized anxiety disorder, and alcohol dependence.Patients diagnosed with PTSD/panic disorder reported a significantly greater proportion of nightmare complaints (96%) and insomnia (100%) compared with the other comorbid groups.A greater proportion of PTSD patients with comorbid panic disorder complain of sleep-related problems than other comorbid groups. This effect appears unique to panic, rather than other general anxiety disorder or depression. Prospective sleep studies are needed to differentiate the role of sleep in PTSD and PD, as well as to examine the role of psychiatric comorbidity in worsening sleep in PTSD patients.

Abstract

OBJECTIVES: (a) To determine the quantity and quality of behavioral problems in older hospitalized patients on acute care units; (b) to determine the burden of these behaviors on staff; and (c) to identify predictors of behavioral problems. METHODS: Upon admission, patients performed the Mini-Mental State Exam (MMSE), the Geriatric Depression Scale (GDS), and information was obtained on age, ethnicity, level of education, living arrangement, and psychiatric history. Two days post-admission, a clinical staff member caring for each patient, performed the Neuropsychiatric Inventory-Questionnaire (NPI-Q) to assess patients' behavioral problems and staff distress. PARTICIPANTS AND SETTING : Forty-two patients, over 60 years of age, admitted to medical and surgical units of the Veterans Affairs Hospitals in Palo Alto and San Francisco, participated. RESULTS: Twenty-three of 42 (55%) patients exhibited behavioral problems. Anxiety, depression, irritability, and agitation/aggression were the most frequently observed behaviors. The severity of the behavioral problems was significantly correlated with staff distress. Lower performance on the MMSE at admission was significantly associated with higher NPI-Q ratings. Specifically, of those cases with scores less than or equal to 27 on the MMSE, 66% had behavioral problems during hospitalization, compared to only 31% of those with scores greater than 27. CONCLUSION: Behavioral problems in older hospitalized patients appear to occur frequently, are a significant source of distress to staff, and can result in the need for psychiatric consultation. Assessment of the mental status of older adults at admission to hospital may be valuable in identifying individuals at increased risk for behavioral problems during hospitalization.

Abstract

To corroborate findings from the National Comorbidy study with objective sleep data.Retrospective data review.Sleep Laboratory, National Center for Posttraumatic Stress DisorderMale Vietnam combat veteran.N/A.We reanalyzed laboratory sleep data obtained from subjects undergoing inpatient treatment for posttraumatic stress disorder. Comorbid panic disorder was not associated with a significant worsening of objective sleep in this sample. Posttraumatic stress disorder, comorbid panic disorder, and trauma-related nightmare complaint were all associated with significant and systematic reductions of sleep movement time. Analyses of potential "rescoring" artifacts provided further support for this effect.A curvilinear function may describe the relationship between anxiety symptom severity and sleep-movement time in both posttraumatic stress disorder and panic disorder. Evidence for movement suppression in association with pathologic levels of human anxiety is consistent with the suppression of movement ("freezing") exhibited by animals under conditions of perceived threat.

Abstract

A number of systems have been proposed for classifying older adults who suffer from cognitive impairment or decline but do not yet meet criteria for Alzheimer's disease (AD). The classification, Mild Cognitive Impairment (MCI), has attracted much attention. It uses relatively specific diagnostic criteria and individuals who meet these criteria appear to be at substantial risk for the development of AD. However, little data is available to define the prevalence of MCI in any age group. We propose a simple mathematical model for the progression of patients from Non-Affected (NA) to MCI to AD. This first-order Markov model defines the likely prevalence of MCI at specific ages. Primary assumptions of the model include an AD prevalence of 1% at age 60 increasing to 25% at age 85 and a conversion rate from MCI to AD of 10% constant across all ages considered. We used the best available information for our model and found (1) that the MCI prevalence increased from 1% at age 60 to 42% at age 85 and (2) that the conversion rate from NA to MCI increased from 1% per year at age 60 to 11% at age 85. In conclusion, this model allows estimation of prevalence of MCI and conversion from NA to MCI based upon known prevalences of AD, conversion rates of MCI to AD, and death rates. Due to its substantial prevalence, MCI may be an important target for screening and possible intervention.

Abstract

We report a randomized, double-blind, parallel group, placebo-controlled study to test the effects of the acetylcholinesterase inhibitor, donepezil (5 mg/d for 30 days), on aircraft pilot performance in 18 licensed pilots with mean age of 52 years. After 30 days of treatment, the donepezil group showed greater ability to retain the capacity to perform a set of complex simulator tasks than the placebo group, p < 0.05. Donepezil appears to have beneficial effects on retention of training on complex aviation tasks in nondemented older adults.

Abstract

Mental health professionals are often called upon to assist institutions in their struggle to manage the behavior problems associated with dementia. The current article provides an example of a typical behavioral consultation. The various methods of assessment, including topographical, functional and observational are described in the context of planning future interventions. Results indicate that a large proportion of staff time, approximately 40%, is spent implementing such interventions. Although the time required is great, frontline staff are adept at utilizing less invasive interventions first. Implications for subsequent interventions, need for continued evaluation and reassessing levels of staff burden are discussed.

Abstract

Several epidemiological studies have demonstrated a higher prevalence of panic disorder in women than in men. This study explored whether the prevalence of specific panic symptoms differs by gender.National Comorbidity Survey data from 609 respondents who met DSM-III-R criteria for panic disorder or panic attacks were analyzed to test for gender differences across 18 panic symptoms.Among National Comorbidity Survey respondents with panic disorder or panic attacks, female respondents were more likely than male respondents to experience respiration-related difficulties during panic attacks.Specific symptoms occurring during panic attacks differ by gender. The pathophysiology of these symptom differences may involve gender differences in sensitivity to CO(2) and in the threshold for panic attacks during hypoxic and hypercapnic states.

Abstract

The purpose of this article is to examine prevalence of lifetime traumatic experiences in a community sample of panic disorder patients.We examined trauma rates in a cohort of panic disorder patients. Also, we statistically disaggregated comorbid PTSD from individuals diagnosed with panic disorder in the National Comorbidity Survey.Panic disorder patients suffer lifetime traumatic experiences at high rates. We found that 24.2% of females and 5% of males with panic disorder reported previous history of being sexually molested.These results suggest that trauma may act as a risk factor for panic disorder, as well as comorbid panic disorder and PTSD.

Abstract

Although there are numerous clinical guidelines regarding the management of dementia, there have been few studies on their implementation in practice. Clinicians in six United States Department of Veterans Affairs medical centers (n = 200, 85% response rate) were surveyed regarding their use of practices recommended in the California Workgroup Guidelines for Alzheimer's Disease Management. The majority of providers (89% to 73%) reported that they routinely conducted neurological examinations, obtained histories from caregivers, discussed the diagnosis with the patient's family, discussed durable power of attorney, and made legally-required reports of drivers with dementia. Roughly two-thirds of providers said they routinely conducted cognitive screening examinations, screened for depression, reported elder abuse, and discussed care needs and decision-making issues with patients' families. Only half of all outpatient providers implemented caregiver support practices for at least half of their patients. Clinicians' choices of medications for cognition, mood, and behavior problems were broadly consistent with current practice guidelines. These results suggest possible priorities for quality improvement efforts. Further research is needed to clarify reasons for particular gaps between guidelines and practice and to identify specific targets for intervention.

Abstract

Clinicians and researchers alike are shifting their focus to elderly patients in order to target the most effective treatments for a variety of psychiatric conditions. Clinical trials with elderly patients are the necessary because they consume the largest number of prescription medications. There are special challenges and considerations in designing and conducting clinical studies. The authors review the various phases of such research, including recruitment of appropriate patients and retention of those enrolled, and they make suggestions, using examples from already completed research studies, illustrating the methods found to be most successful.

Abstract

The current study explored the relationship between past traumatic experiences and current depression in a sample of depressed older adult primary care patients.Sixty-six patients were referred from primary care to a psychogeriatric clinic that specialized in the treatment of unipolar depressive disorders. All patients received an extensive psychological assessment.Twenty-one percent had a history of trauma reported in their medical charts. Despite no differences found on a clinician-rated measure of depression, those with a trauma history had more depressive symptoms on a self-report measure.Although older patients with a history of trauma may not appear more depressed than a non-trauma comparison group, they may be in more psychological distress. The clinical implications of these findings and recommendations for mental health professionals are discussed.

Abstract

Data from two fixed-dose studies of sertraline in panic disorder were pooled in order to provide sufficient power for the analysis of treatment response in clinically relevant subgroups. Male and non-fertile female patients meeting DSM-III-R criteria for moderate-to-severe panic disorder with or without agoraphobia completed a 1-2 week placebo run-in period, and then were randomized to 12 weeks of double-blind treatment with either placebo, or one of three fixed daily doses of sertraline (50 mg, 100 mg, or 200 mg). Eighty-two patients were treated with placebo and 240 patients were treated with one of three doses of sertraline. All three sertraline doses produced significant efficacy compared to placebo, with no consistent evidence of a dose-response effect. For the subset of patients with subsyndromic depression at baseline [baseline Hamilton Depression Rating scale (HAM-D > 12 and < or = 21], sertraline yielded a significantly higher panic-free rate than did placebo (P = 0.021), again, by a conservative endpoint (Last Observation Carried Forward method, LOCF) analysis. Sertraline was well-tolerated at all dose levels, with no significant between-dose differences in patients discontinuing due to adverse events. The presence of mild-to-moderate subsyndromic levels of depression did not reduce the anti-panic efficacy of sertraline.

Post-traumatic amnesia after closed head injury: a review of the literature and some suggestions for further researchBRAIN INJURYAhmed, S., Bierley, R., Sheikh, J. I., Date, E. S.2000; 14 (9): 765-780

Abstract

Post-traumatic amnesia (PTA) is a transient sequela of closed head injury (CHI). The term PTA has been in clinical use for over half a century, and generally refers to the subacute phase of recovery immediately after unconsciousness following CHI. The duration of PTA predicts functional outcome after CHI, but its pathophysiological mechanism is not known. This paper compares current methods of determining the duration of PTA, summarizes reports on neuropsychological deficits in PTA, reviews available data that allow inferences about its mechanism, and suggests methods for further exploration of its pathophysiology.

Abstract

In a 24-patient case series from retrospective chart review, the authors examined the use of gabapentin for the treatment of aggressive and agitated behaviors in nursing home patients with a DSM-IV diagnosis of dementia. On Clinical Global Rating Scale scores, 17 of 22 patients were much or greatly improved; 4 were minimally improved; and only 1 remained unchanged. Two of the 24 patients discontinued use of the medication because of excessive sedation. No other significant side effects were noted in treatment lasting up to 2 years.

Abstract

Clinical practice for the treatment of anxiety disorders in the elderly in general lacks empirical validation and hence is somewhat inconsistent. Extensive clinical experience, along with the knowledge gleaned from studies with a younger population, has led to the development of the following treatment approach. A thorough diagnostic assessment, crucial in planning subsequent treatment, is discussed first along with more general clinical issues. Next. a detailed review of current pharmacologic and psychologic treatments for each of the diagnostic categories of anxiety is described for application to the older patient. Definitive studies regarding the best treatments for anxiety disorders in the elderly are lacking, and further investigation of this area is emphasized.

Abstract

Divalproex is now commonly used to treat bipolar disorder in older patients. However, it has yet to be systematically studied in this population. This report describes six older bipolar patients treated with divalproex. Of the six, five showed some improvement with divalproex alone or in combination with other agents. Clearly, a double-blind, placebo-controlled study is an important next step to assess this promising medication.

Abstract

Several studies have documented that a variety of pharmacological compounds are quite effective in controlling acute symptomatology of panic disorder in the general population. However, there is a paucity of such studies in the management of panic disorder in older adults (ages 55 and above). The purpose of this study was to gather pilot data in older patients with panic disorder to begin to assess the efficacy of two commonly-used antipanic medications, imipramine and alprazolam.Twenty-five (n = 25 (23 females; 2 males); 18 completers, 7 dropouts) older panic disorder (DSM-III-R) patients (age range = 55-73; mean = 61.24) were studied in an eight-week randomized, parallel-groups, double-blind, placebo-controlled, flexible dose design. Outcome was assessed weekly by global change ratings (Hamilton Anxiety and Depression Scales; Physicians' Global Impression ratings) and panic diaries. Because of small sample size, we present data descriptively.Subjects in active medication groups evidenced reductions in panic attacks and in level of overall anxiety and depression. Therapeutic dosages were approximately half those commonly used in younger panic disorder patients.Our data suggest the comparable efficacy of alprazolam and imipramine in the short-term treatment of older adults with panic disorder. There is clearly the need for a larger scale placebo-controlled study, preferably comparing imipramine and/or alprazolam with one of the SSRIs, to substantiate our findings.

Abstract

The authors present a case report with details of an unusual presentation of panic disorder and shared symptomatology in a long-married elderly couple. At the initial diagnostic clinical interview, the couple shared in common six symptoms of panic disorder (husband with a total of six symptoms, wife with a total of eight symptoms) and manifested commonalities in avoidance behaviors. Authors discuss the duration and course of each patient's disorder, symptoms, and commonalities.

Abstract

This article reports cross-sectional and follow-up data with actigraphic measures of nocturnal sleep and rest/activity in 61 Alzheimer's disease (AD) patients as well as the relation of actigraphic measures to levels of behavioral disturbance across different stages of the disease. Over the course of approximately 1.5 years' follow-up, patients showed significant deterioration of nocturnal sleep parameters, but no significant change in rest/activity circadian rhythm parameters. There were also significant correlations among nocturnal sleep, rest/activity circadian rhythm, and behavioral disturbance measures, but only in relatively early stages of AD. It is argued that study of nocturnal sleep and circadian rhythm in relation to behavioral disturbance in AD requires longitudinal data and analyses that take into account the stage of disease at which patients are assessed.

Abstract

Traditional lore suggests that anxiety disorders are less prevalent in elderly than in younger adults, and late-onset anxiety disorders are especially rare. We question these assumptions, and suggest that these conditions are underdiagnosed in late life. A common problem in the literature is the application of DSM-IV-like criteria developed from studies of younger adults to geriatric samples without regard for atypical symptom presentations, high occurrence of depressive and medical co-morbidity, and influence of aging-related psychosocial changes on the clinical picture. Diagnostic problems are further compounded by therapeutic ones. Clinicians are often forced to make treatment decisions for their elderly patients based on uncontrolled clinical observations or questionable extrapolation of treatment data in younger adults. An open-minded approach unhinged by 'conventional wisdom' is warranted.

Abstract

Approximately one quarter of patients with AD-type dementia reportedly exhibit disruptive, restless, and/or confused behavior that tends to be more apparent in late afternoon or early evening. Research has yet to document the phenomenon in a definitive manner to facilitate standardized assessment and clinical trials. Recent work attempting to define precisely the prevalence of abnormal behaviors during different periods of time of day in AD patients is reviewed. Caregiver reports of confusion and aggressive, disruptive behavior have been associated with going to bed early, increased use of sedative-hypnotics, and more severe cognitive impairment. Because there is evidence that the sleep of many AD patients is of poor quality, one might try to treat such patients with behavioral approaches useful in insomnia in other populations. Futhermore, as psychotropic medications can adversely affect sleep and/or have "hangover" effects on daytime cognition, one should carefully manage these medications to optimize care. Advances in assessment of sundowning, combined with longitudinal studies of sleep and circadian rhythm changes associated with dementia progression, should enhance efforts to treat behavioral and sleep disturbances.

Abstract

Despite increasing research interest in the area of anxiety in younger age groups, few systematic studies of the course and treatment of anxiety disorders in the elderly have been performed. Data from Epidemiologic Catchment Area (ECA) studies suggest that anxiety disorders remain among the most prevalent of all psychiatric disorders in this age group. There is little information available about the late onset of anxiety disorders except for some evidence regarding panic disorder that suggests a distinct subtype with late onset and differences in vulnerability factors and phenomenology. Any evaluation of anxiety in the elderly should take into account multiple medical illnesses and medications that can produce a similar symptom picture. Thus, the importance of good history-taking, empathy to the patient's psychosocial situation, and awareness of the possibility of an underlying medical condition cannot be overemphasized. A variety of compounds including benzodiazepines, buspirone, antidepressants, and beta blockers seems to show effectiveness for various anxiety disorders of the elderly. One needs to be cognizant of the great individual variation among the elderly and should be ready and willing to tailor usage of medications or cognitive-behavioral techniques to the patient's special needs. Proper education of the patient, leading to better compliance with the treatment regimen, and recent advances in treatment will almost certainly improve the outlook for these patients in the future for better functioning and a more optimistic prognosis.

Abstract

Anxiety disorders appear to be among the most common psychiatric illnesses of the elderly. Although systematic studies of the phenomenology and treatment of anxiety disorders in the elderly are rather scant, inferences based on studies of younger patients combined with careful clinical observations can be very helpful for both diagnostic and treatment purposes. Several medical conditions can mimic anxiety disorders and suggest a need to consider a possible underlying organic condition during the process of evaluation. Clinical evaluation should be complemented by rating scales and laboratory tests where appropriate. Anxiety disorders occurring for the first time in late life appear to be milder in symptomatology than early-onset disorders. Most anxiety disorders can be well managed using the available treatments. It appears that short-acting benzodiazepines, such as oxazepam and lorazepam, are the treatment of choice for short-term symptoms of geriatric anxiety. For anxiety of longer durations (e.g., greater than 6 months), a nonbenzodiazepine such as buspirone seems preferable. Antidepressants seem effective in cases of mixed anxiety-depression or panic disorder. There is clearly a need, however, to perform more controlled clinical trials of these medications to establish empirically derived guidelines for safety, efficacy, and specificity of these drugs for the elderly population. Finally, nonpharmacologic methods such as cognitive-behavioral treatments can be very effective for the management of certain anxiety disorders, particularly phobias.

Abstract

Studies of panic attacks in older adults are virtually nonexistent. The authors surveyed 520 adults with panic attacks; 445 were younger than age 55, 57 were 55 years old or older but had their first panic attack before age 55, and 18 were 55 years old or older and had their first panic attack at age 55 or later. The respondents with late-onset panic attacks reported fewer symptoms during their attacks and were less avoidant than both groups of respondents with early-onset panic attacks.

Abstract

The Geriatric Depression Scale (GDS) is commonly used to measure depression in the elderly. However, there have been no reports of the underlying structure of the GDS. To this end, the GDS was administered to 326 community-dwelling elderly subjects, and the data were subjected to a factor analysis. A five-factor solution was selected and, after a varimax rotation, the factors that emerged could be described as: (1) sad mood, (2) lack of energy, (3) positive mood, (4) agitation, and (5) social withdrawal. This solution accounted for 42.9% of the variance. Knowledge of the factor structure should aid both clinicians and researchers in the interpretation of responses on the GDS.

Abstract

Psychopharmacological studies usually attempt to eliminate "nonspecific" influences on outcome by double-blind designs. In a randomized, double-blind comparison of alprazolam, imipramine, and placebo, the great majority of panic disorder patients (N = 59) and their physicians were able to rate accurately whether active drug or placebo had been given. Moreover, physicians could distinguish between the two types of active drugs. Inasmuch as correct rating was possible halfway through treatment, concerns about the internal validity of the double-blind strategy arise.

Abstract

While many research studies have investigated memory training for elders, none have asked which specific memory skills elders would like to improve. This study investigates two related questions. First, which memory skills elders would like to improve? Second, is there a common set of these memory skills? Elders completed a three-part questionnaire. First, it asked for subject demographics. Second, it asked for the first, second, third, and then all other memory skills they would most like to improve. Finally, it asked elders to rate the importance of 10 specific memory skills. The results indicate that elders share a common set of memory skills they wish to improve. They are: (a) people's names, (b) important dates, (c) location of household objects, (d) recent and past events, (e) meetings and appointments, (f) information and facts, (g) general improvement, and (h) medication. One conclusion from these findings is that at least some memory training research should focus on these specific memory skills.

Abstract

Previously validated methods of memory training were used in conjunction with the Folstein Mini-Mental State Examination (MMSE) to explore the relationship between complexity of learned mnemonic, aging, and subtle cognitive impairment. Subjects were 218 community-dwelling elderly. Treatment included imagery mnemonics for remembering names and faces and lists. There was a significant interaction among age, type of learning task (face-name vs. list), and improvement when controlling for MMSE score. There was also a significant interaction among MMSE score, type of learning task, and improvement when controlling for age. Scores on the more complex list-learning mnemonic were more affected by age and MMSE scores than were scores on the face-name mnemonic. Implications of the findings for cognitive training of the old old and the impaired are discussed.

Abstract

Prescription medication nonadherence among the elderly is a serious medical problem. Nonadherence is primarily caused by poor communication between health professionals and elderly patients. More specifically, nonadherence often reflects the inability of patients to understand and remember their medication instructions. Therefore, adherence can be increased by designing instructions that enable elders to easily construct a clear and simple mental model of how to take their medication. Inexpensive microcomputer-based hardware and software makes it possible for pharmacists to provide elderly patients with effective instructions.

Abstract

This study investigates three questions related to the problem of medication nonadherence among elders. First, does recall failure play a significant role in nonadherence? Recent research suggests that it may not. Second, can the new portable bar code scanner technology be used to study nonadherence? Other forms of monitoring are obtrusive or inaccurate. Finally, can inexpensive computer assisted instructions (CAI) be used to teach mnemonic techniques specifically designed to improve medication schedule recall? Current research on memory training teaches nonspecific mnemonics and uses the expensive classroom approach. Results of the present study suggest that physically active and cognitively alert elders do have significant nonadherence (control group = 32.0%) problems related to forgetting and that CAI courseware can significantly reduce (medication recall training group = 10.0%) this form of nonadherence. Portable bar code technology proved easy to use by elderly patients and provided detailed information about the type of forgetting underlying nonadherence. Most significant recall failure was in the complete forgetting to take medication rather than delays in medicating or overmedicating.

Abstract

Prior studies have documented the effectiveness of several types of memory training for the elderly with normal age-related memory losses. Despite these positive results, there is substantial variability of individual response to treatment. The authors describe attributes of individuals most likely to benefit from two types of memory training. They found that for 40 elderly volunteers performance on the WAIS vocabulary subscale correlated with response to a treatment combining mnemonics and verbal elaboration techniques and scores on the Spielberger State-Trait Anxiety Inventory correlated with response to a treatment combining mnemonics and relaxation techniques.

Abstract

One hundred twenty-eight elderly adults were recruited to assess the effects of affective judgment, imagery, and relaxation pretraining on mnemonic training. Participants were assigned to one of the following conditions: (1) visual imagery and affective judgment pretraining plus mnemonic training, (2) visual imagery pretraining only plus mnemonic training, (3) relaxation pretraining plus mnemonic training, (4) nonspecific pretraining plus mnemonic training, (5) nonspecific pretraining only, and (6) wait list. Subjects were tested at three times: prior to training (Time 1), following pretraining (Time 2), and at the conclusion of mnemonic training (Time 3). Although those receiving active pretraining plus mnemonics did not differ from one another at Time 3, they recalled more than those with no active pretraining. The results suggest that for mnemonics to be effective they should be coupled with active pretraining techniques.

Abstract

The purpose of this investigation was to determine the relationship between serum levels of the neuroleptic agent thiothixene and tardive dyskinesia in schizophrenics of a wide age range. Forty-one male schizophrenic subjects, 21 with tardive dyskinesia and 20 without, were given a fixed dosage of thiothixene hydrochloride (10 mg orally four times daily) after a drug-free period of one week. Higher steady-state serum levels of thiothixene (obtained after five days of a fixed-dosage schedule) were associated with greater degrees of tardive dyskinesia. This relationship was independent of the relationship between tardive dyskinesia and age.

Abstract

A visual-imagery mnemonic was used as a memory training aid for a 66-year-old patient with primary degenerative dementia. Length of retention time was used as the primary outcome measure. The application of the mnemonic procedure extended the length of retention time for name-face recall from baseline. Performance gains were sustained at one month.

Abstract

This study examined the effects of memory training on the relationship between perceived recall confidence and recall performance. The sample consisted of 76 elderly, community dwelling volunteers. Fifty-nine individuals received eight hours of memory training; the remaining 17 were wait-list controls. Participants were tested at pre- and post-intervention, and rated their confidence for recall of name-face pairs prior to each testing. The results showed a significant improvement in name-face recall at post test, favoring the group receiving mnemonic training. There was a significant association found between confidence ratings and recall performance at post-test. A closer examination of standardized regression residuals (confidence ratings and number of name-face pairs recalled) revealed that with mnemonic training, there was an improvement in the relationship between perceived confidence and recall performance following mnemonic training. The results suggest that the ability to assess changes in recall capacity and to judge future memory performance is enhanced by exposure to mnemonic training.

Abstract

Ten patients with panic disorder or agoraphobia with panic attacks and 10 normal controls received infusions of normal saline (placebo) and sodium lactate in a single-blind design. The time course of changes in the dependent variables was closely monitored, and expectancy biases and demand characteristics were minimized. Lactate increased self-reported anxiety and heart rate equally in patients and controls. The only variables showing statistically different responses between the groups were systolic and diastolic blood pressure. Overall, in both groups, the effects of lactate were quite similar to states of natural panic or anxiety for both self-report measures and heart rate. Patients had a tendency to endorse somatic symptoms indiscriminately. Our data do not support response to lactate as a biological marker of proneness to panic attacks.

Abstract

Of 33 "panic" attacks reported by patients wearing an ambulatory solid-state heart rate/activity monitor for 6 days, 19 (58%) occurred at heart rates disproportionate to activity levels and different enough from surrounding heart rates to indicate a distinct physiologic state. Intense panic attacks with three or more symptoms were the most readily identified. ECG monitoring found the elevated heart rates to be sinus tachycardias. Heart rate elevation did not occur during anticipatory anxiety episodes. Ambulatory heart rate recordings confirm the presence of major physiologic changes during self-reported panic attacks.